Provider Demographics
NPI:1134445679
Name:BENES, ANGELA JEAN (MS, SLP-CCC)
Entity type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:JEAN
Last Name:BENES
Suffix:
Gender:F
Credentials:MS, SLP-CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4100 JURUPA ST
Mailing Address - Street 2:SUITE 108
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91761-1420
Mailing Address - Country:US
Mailing Address - Phone:909-390-1313
Mailing Address - Fax:909-390-1311
Practice Address - Street 1:4100 JURUPA ST
Practice Address - Street 2:SUITE 108
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91761-1420
Practice Address - Country:US
Practice Address - Phone:909-390-1313
Practice Address - Fax:909-390-1311
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-08
Last Update Date:2015-06-24
Deactivation Date:2015-05-27
Deactivation Code:
Reactivation Date:2015-06-24
Provider Licenses
StateLicense IDTaxonomies
CASP16940235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist